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y , APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601-E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 4666781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i r. r+ ..:.. (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. /J Job Address C� City �� Lot Size PM / 'f �� `4.1 Owner's Name Address Phone f Contractor 1`�^ Address ! $� t '1 License N1. D57Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEA4EST;. SEPTIC TANK .,SEWER,SEWER LINES-:_ DISPOSAL FLD._-;_ PROP. LINE FOUNDATION AGRICULTURE WELL --OTHER'WELLPITS/SUMPS _, -- _._4 INTENDED USE TYPE OF'W'ELL• PROBLEM AREA. CONSTRUCTION SPECIFICATIONS , 4' 1:1Industrial l❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private a Gravel Pack ❑ Tracy Type of Casing .F Specifications ❑ Public ❑ Other ❑ Deltas Depth of Grout Seai ',`r s k Type of Grout ❑ Irrigation �pprox. Depth ❑ Eastem�-�-- --Surf Seal Installed by Repair Work Done ❑ iType of Pump H.P. �e ;' State Work Done} Well Destruction Cl Well Diameter Sealing Material (top'50'1 i Depth Filler Material ( 'slow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION MTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial____ Other i J3 .�. tm f i g i I Number of living units:j Number o bedrooms f! '.- I 40 Character of soil to a depth of 3 feet: e_ r l ` Water table depth SEPTIC TANK ❑ Type/Mfg' .„ Capacity � - No. Compartments PKG. TREATMENT PLT. ID _ J __Vf Method of Disposal ,r -,.r - t Distance to nearest: Well:r Foundation t Property Line�` r LEACHING LINE IFI�No. &Length of line Total length/size FILTER BED ❑ Distance to nearest: Welldr Foundation Property Lie SEEPAGE PITS C Depth S Size �a - Number t SUMPS ❑ Distance to nearest: Well Foundation M:�r Property Line a DISPOSAL PONDS ❑ ire i< l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin bounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. y Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.”Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." ! Y € The applicant must call for all.re fired i Factions. Complete drawing on reverse side.SignedTitle: !1 A�C� - Date: f FOR DEPARTMENT USE ONLY Application Accepted by Date Area J(__1 Pit or Grout Inspection by Dates Final Inspection by Date i Additional Comments: ❑ 5tk 466-6781 C7 Lodi 369 3621 El Manteca 823-7104 ❑ Tracy 835-63�i 4 Applicant- Return all copies to: Envir Amental_Health Permit/Services 1601 E. Hazelton Ave., P. Box 2009, Stk., CA 95201 FEE AMDUNt DUE AMOUNT REMITTED, CASH RECEIVED BY DATE PERMIT•'NO. INFO 3 _y-Si ?1 + EH 13241REY,i/a5) Q , �/ Crh W GH 14-28